Attach Photo
APPLICATION FOR ENROLLMENT
ANTICIPATED STARTING DATE
THIS FORM MUST BE ACCOMPANIED BY:
1. One passport sized photograph
2. Report card of current and/or previous school year (or school Transcript)
3. Copy of Proof of residency for parent(s)/guardian(s) and student (e.g., resident card,
passport, Jumin hyo/住民票)
4. Copy of current health insurance card
5. Document from physician stating that there are no major health problems prohibiting the
child from participating regularly in school (May be submitted before starting classes)
6. Sign and submit Parent/ Legal Guardian Agreement
PLEASE TYPE ALL SECTIONS
1. STUDENT INFORMATION
First Name Middle Name Surname Age Gender Date of Birth
M・ F (dd/mm/yy)
Nationality Religion Languages spoken at home
Address Telephone
Email Mobile
Explain transportation to and from school
2. PARENT/GUARDIAN INFORMATION
Please provide the following information on the persons legally responsible for the applicant.
A. Relationship to child: Mother/Father/Guardian
First Name Middle Name Surname Nationality Languages
Occupation Employer
Address Home Telephone
Email Mobile
B. Relationship to child: Mother/Father/Guardian
First Name Middle Name Surname Nationality Languages
Occupation Employer
Address Home Telephone
Email Mobile
3. ADDITIONAL EMERGENCY CONTACT INFORMATION
Please name an adult other than parents or guardian to be contacted if parents are unreachable.
Name Mobile
Email Relationship
4. ACADEMIC INFORMATION
Please list ALL schools that your child has previously attended beginning with the most recent
school (include Kindergarten and Pre-school experiences).
Name of School Country Language of Type of Year Attended Grade Level(S)
Instruction Curriculum (MM/YYYY)
to
to
to
to
to
Please list any extracurricular activities in which your child has participated. If he/she has received any
award or special recognition, please mention it.
5. STUDENT MEDICAL INFORMATION
Normal Body Temperature Allergies Other medical conditions
Name of Family Physician Name of Clinic Phone
Please state any other information that you feel may be important for the school to know about your
child.
Liberty International School
Parent/Guardian Agreement
STUDENT NAME
Last name First name Middle name
1. I understand that the filling out of this application 7. I understand that photographs and videos of my
does not guarantee acceptance into Liberty International child(ren) may be taken to be used in various formats (e.g.,
School and Liberty International School reserves the right printed or digital media). I hereby grant Liberty
to accept or reject any student applying for admission. International School permission to use, publish and
reproduce for any legitimate purpose excerpts from printed
2. I understand that upon acceptance of my child to or digital content, such as may be retrieved from written
Liberty International School, I am responsible for the fees art works, essays, or school activities, etc. This media may
and tuition for the full year, unless noted differently in be used for professional development and educational
the tuition contract I sign. research. Identifiable information will not be displayed.
3. I understand that before the first day of attendance,
fees and tuition must be paid in full or an Installment 8. I voluntarily relinquish any claim against Liberty
Payment Plan must be in effect. International School, its governing authorities,
administrators, teachers, and volunteers, in the case of any
4. REFUND – I understand that if the need arises to accident my child(ren) may be involved in while at school,
withdraw a student before the new school year begins, a on any school outing or activity, and during transportation
refund of annual fees and tuition will be given. If a to and from school.
student must be withdrawn during the school year but
before the second term begins, a refund of tuition for the 9. If a parent or legal guardian cannot be contacted in
second term will be given. In this case, the parent or the event of an accident or injury to my child(ren), I
guardian will need to notify the school in writing. authorize Liberty International School officials to take
NOTE: In order to receive a refund, this notification must whatever action they deem to be necessary in order to
be received before the first day of classes for the assure the best health care for my child(ren).
specific term.
10. I understand that Liberty International School
5. I understand that Liberty International School has the provides children an equal opportunity for education.
right to prohibit any student from participating in an Things such as, but not limited to, nationality, race, color,
activity if that student's behavior negatively affects other gender, or religion will not be a factor prohibiting
students or classroom functions. Furthermore, I a student from attendance.
understand that the school may permanently disenroll a
student for behavior that violates or conflicts with the 11. I understand that as a general rule, if I unenroll
mission and vision of the school. Furthermore, no refund my student from Liberty International School and then later
of fees or tuition will be granted in this case. decide to return to the school, I will need to redo the
application and pay the one-time fees again. In
6. I understand that Liberty International School has the such situations, I understand that a space for my
right to assess the grade level and language level of each student is not guaranteed upon returning. Exceptions
student in attendance. to this rule may be given at the discretion of the
administration.
Signatures
Parent 1/Legal Guardian Date
Parent 2/Legal Guardian Date
OFFICE USE ONLY
Year Starting Date Bus Agreement Registrar sign Date
Enroll ID Textbook Paid By Office sign Date
ACCEPTANCE OF ENROLLMENT
The enrollment of is accepted to commence classes on
Signed Date
Operations Manager Head of School dd/mm/yy
SPECIAL CONDITION OF ENROLLMENT
This enrollment is accepted contingent on the following special conditions:
Signed Date
Operations Manager Head of School dd/mm/yy
